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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602851
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:06:31 PM


Document Has Been Signed on 08/22/2024 06:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GENESEE VILLAFACILITY NUMBER:
197602851
ADMINISTRATOR:MARIA CLARKFACILITY TYPE:
740
ADDRESS:1441 GENESEETELEPHONE:
(323) 935-2244
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY:6CENSUS: 6DATE:
08/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria ClarkTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an annual inspection visit. LPA was allowed entry by Administrator Maria Clark. LPA discussed the purpose of today’s visit.
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The facility is licensed to serve 6 ambulatory and 1 non-ambulatory elderly residents age 59 and over. Currently, there are six (6) residents placement.

The facility consists of : a two story facility which consists of: living room, kitchen with dining area, office, detached laundry room, five (5) bedrooms, three (3) bathrooms.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Facility has an Infection Control Plan in place.

Operational Requirements: Facility is adhering to the operational requirements.

Physical Plant & Environment Safety: LPA toured facility grounds. The furniture in the dining room was adequate and the kitchen was clean. The appliances were working properly. The refrigerators and freezer are set at appropriate temperatures. LPA toured resident rooms which are located on both floors. The facility has smoke detectors and fire extinguisher(s). The hallways and stairway are clear and free of any obstructions. Resident rooms were observed to be clean, properly furnished and have the required linen which were in good condition. There was adequate lighting throughout the facility. All resident rooms had appropriate

**Continued on LIC809C**
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GENESEE VILLA
FACILITY NUMBER: 197602851
VISIT DATE: 08/22/2024
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storage for resident's personal belongings. The hot water was tested and was within Title 22 regulations at 107 degrees. Restrooms were observed to be clean, and operational. There is no pool or large bodies of water on the premises. A comfortable temperature was maintained throughout the facility.

Staffing: Facility is adhering to staffing requirements.

Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator and Staff 1-2 (S1-2). Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file.

Resident Rights-Information: Resident rights are posted and included in Resident files.

Planned Activities: Activity schedule is posted.



Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Posted menu observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Dining areas have adequate seating.

Resident Records-Incident Reports: LPA reviewed Resident files for Resident 1-6 (R1-6). Resident files are maintained at the facility. Resident files have the required documents.

Disaster Preparedness: The facility has a Disaster Preparedness plan in place.



Residents with Special Health Needs:
Per Administrator, there are no residents with postural supports and no residents with prohibited health conditions. Per Administrator, there are (0) residents utilizing oxygen equipment.

Health Related Services/Incidental Medical Services: The medications are stored/ locked inside the medication room and are inaccessible to residents.

Exit interview conducted, and a copy of this report was provided to Administrator Maria Clark.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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